Imaging Diagnosis and Staging of Lung Cancer By Mamdouh Mahfouz MD Radio diagnosis Cairo University

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1 Imaging Diagnosis and Staging of Lung Cancer By Mamdouh Mahfouz MD Radio diagnosis Cairo University

2 Lung Cancer The most common cause of deaths worldwide Cigarette smoking is by far the most common risk factor accounting for 90% Four main histologic groups Adenocarcinoma 35% Squamous cell carcinoma 30% Small cell carcinoma 20% Large cell carcinoma 15%

3 Imaging strategy Characterization of the primary lesion Local relationship to the pleura, chest wall, mediastinum and airways Distant tumor spread to the bones, liver, brain and suprarenal glands

4 Characterization of the primary lesion Peripheral nodule Benign characters: small< 2cm, rounded, smooth edge, with calcium and no change in size over 2 years period Malignant characters: more than 2.5 cm, spiculated edge, no calcium Helpful clinical data: patient s age and smoking

5 Benign pulmonary nodule with smooth edge and central calcifications

6

7 Bronchogenic carcinoma Malignant pulmonary nodule with speculated edge and ipsilateral deposits

8 Peripheral Bronchogenic carcinoma Solitary peripheral subpleural nodule 52% Upper lobe distribution 70% Calcification 1% Speculated margin due to demoplastic reaction

9

10 Characterization of the primary lesion Peripheral nodule Dynamic CT or MR Imaging Malignant nodules produce significant increase in density or signal intensity than benign nodules in the first transit of contrast bolus DD pulmonary AVM

11 Characterization of the primary lesion Peripheral or central mass Solid mass lesion of whatever edge, matrix Central areas of necrosis and breakdown Areas of matrix calcification [7-14% of cases] Smooth, lobulated, speculated edge Pleural tail?!

12 Central and peripheral bronchogenic Carcinomas

13 M 62 Y with chest pain and hemoptysis

14 M 49Y

15 M 49Y

16 Calcium is present in 7-14% of Bronchogenic carcinomas Bronchogenic carcinoma with central breakdown and pleural tails

17 M 62Y

18 M 63Y Bronchog enic Ca. with break down on follow up 3 months

19 M 44Y had thyroid cancer treated with thyroidectomy, recently developed chest pain 1 st Xray showed rt sided opacity diagnosed as pneumonia with no response to treatment 2 nd Xray showed progression of the disease and CT was done

20 Peripheral mass lesion Assessment of chest wall invasion [was considered a contraindication for surgical excision of lung cancer] MRI is more sensitive than CT in detection of chest wall invasion Imaging signs of chest wall invasion Rib destruction [CT] Tumor extension beyond the chest wall [MRI]

21 M 70Y M 65Y Chest wall invasion MRI Can differentiate tumor tissue from chest wall muscles

22 Chest wall invasion MRI advantages MRI advantages Multiplanar imaging Can differentiate tumor tissue from chest wall muscles Cine MRI during breathing can assess the tumor movement against the pleural surface In Pancoast s tumors, MR can assess invasion of the brachial plexus and subclavian vessels The accuracy of MRI versus CT in this domain in 94% for MRI compared to 63% for CT

23 M 45Y PANCOAST S TUMOR Apical bronchogenic carcinoma [Pancaost s tumor] with chest wall invasion

24 M 54Y Pancoast s tumors, MR can assess invasion of the brachial plexus, subclavian vessels and the spine

25 Central mass Airway involvement Mediastinal invasion Bronchial obstruction by the primary tumor obstructive pneumonia and atelectasis The anatomy of the bronchi is better assessed by CT separation of tumor tissue from atelectasis is better by MRI

26 M 65Y Central bronchogenic carcinoma with bronchial obstruction and atelectasis

27 F 45Y Central lung cancer and atelectasis

28 Central mass Mediastinal invasion Minimal invasion= tumor within the mediastinal fat = may be amenable for surgical resection Gross invasion = involvement of vital structures= precludes surgical resection

29 M 64Y Bronchogenic carcinoma with mediastinal invasion and lymphadenopathy

30 M 41Y Large cell cancer with mediastinal fat invasion and contralateral nodes

31 Gross Mediastinal invasion M 56Y Superior vena cava Pulmonary arteries Pericardium and heart Invasion of left atrium

32 M 70Y SVC occlusion M 64Y Encasement of the pulmonary artery Bronchogenic carcinoma with mediastinal invasion

33 Bronchogenic carcinoma with mediastinal invasion And fistulous communication with esophagus

34 Mediastinal lymph nodes A cut off size of 10 mm about 60% sensitivity 13% of normal sized nodes contains tumor tissue 37% of nodes measuring 2-4 cm may not be malignant Detection of calcium in the nodes = benign nature PET achieved a high degree of accuracy in assessment of nodal metastases. [93% sensitivity, 99% specificity]

35 M 55Y Peripheral bronchogenic carcioma with positive axillary and mediastinal nodes by PET Scan

36 Percutaneous transthoracic needle biopsy Well established tool in diagnosis of lung cancer in up to 95% of cases Allows early diagnosis Used for diagnosis of lung nodules, masses or infilterates specially if malignancy is suspected Can assess Metastatic disease to lymph nodes and chest wall for staging of the primary lesion Helps to establish a definite diagnosis of non small cell cancer or benign lesion before surgery

37 Percutaneous transthoracic needle biopsy Criteria for optimal procedure Peripheral lesion More than 2cm Short need tract Perpendicular pathway No obstacles in the needle way - Bone - Major vessels - Emphysematous bulla

38 Steps of PTNB

39 Steps of PTNB

40 PTNB complications Pneumothorax 30% Usually small, asymptomatic, stable Develops immediately following the procedure The rate of significant post biopsy pneumothorax requiring intervention is about 6%, increased by - Patient s age COPD - Grater depth of the lesion - Multiple trials

41 PTNB complications Hemoptysis 5-10% Self- limited Massive fatal hemoptysis - Large- calibre needle > 18 G - Low prothrombin concentration <50% Other less common complications as airembolism, tumor implantation along the needle tract, hemothorax,.

42 PTNB complications Factors that increase the incidence of complications Severe COPD Bleeding disorders Pulmonary arterial hypertension Suspected pulmonary AVM Small size of the lesion

43 Imaging of distant tumor spread Metastatic spread usually affect Brain Suprarenal glands Liver and bones

44 Tumor Staging T1 Tumor less than 3cm not invading the main bronchi Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

45 Tumor Staging T2 Tumor more than 3cm Invading the pleura Invading the main bronchi 2cm or more distal to the carina Associated with atelectasis Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

46 Tumor Staging T3Tumor of any size with Invading the pleura, chest wall, diaphragm, pericardium Invading the main bronchi less than 2cm from the carina Associated with atelectasis of the whole lung Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

47 Tumor Staging T4Tumor of any size Invading the mediastinum, heart, spine,major vessels Malignant effusion 47 Y Female with undifferentiated carcinoma grade III invading the heart Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

48 Lymph node Staging No nodes = best prognosis N1 patients are still candidates for surgery with lower 5- year survival rate N1 Ipsilateral nodes Peribronchial Hilar Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

49 Lymph node Staging N2 patients do not benefit from surgery N2 Ipsilateral nodes Mediastinal Subcarinal Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

50 Lymph node Staging N3 patients are not surgical candidates N3 Contralateral nodes Contralateral hilum Contralateral mediastinum Supraclavicular Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

51 Mediastinal lymph nodes Affect the prognosis and therapeutic decisions The prognosis is best in absence of nodal disease N 1 patients are still candidates for surgery with lower 5- year survival rate N 2 patients do not benefit from surgery N 3 patients are not surgical candidates Imaging depend only on the size of lymph nodes

52 Thank you سبحانك اللهم و بحمدك نشهد ان ال اله اال انت نستغفرك و نتوب اليك

53 سبحانك الهم و بحمدك نشهد ان ال اله اال انت نستغفرك و نتوب اليك Thank you

54 M 72Y CT shows minor changes at the left hilum MRI shows endobronchial mass

55 Paratrachial Retrocaval Hilar and carinal Prevascular Hilar and pre carinal

56 Final Staging I : II : III : IV: Beahrs OH,et al. Manual for cancer staging 4 th ed Philadelphia,1992

57 M 61Y

58

59 Sarcoid with follow up

60 M 57Y M 55Y Prevascular Retrocaval

61

62 F 70 with abdominal pain, US showed splenomegaly,ct showed LNs+ lung deposits

63 60 Y M Peripheral bronchogenic carcinoma with metastatic lymphadenopathy and lymphangitis carcinomatosa

64

65

66

67

68

69

70

71

72

73

74

75 Cavitating neoplasm

76 M 42Y Central adenocarcinoma with deposits in the lung and nodes

77 F47Y with chronic cough 4 years, sarcoidosis

78 Miliary TB

79

80 M 76Y

81

82 ANATOMY

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